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Membership Application Form

Personal Information: * REQUIRED INFORMATION

  
*First Name:
*Last Name:
*Address:
*City:
*State:
*Postal Code:
Country:
Home Phone Number:
Work Phone Number:
*Email:
*Occupation:
Degree:
     

Directory of Members

 

Do you wish to be listed in the Directory?

 
YES
  
NO
    

If YES, please check which of the following contact information you wish to be included:

Email:
    
Work Phone Number:
 

If you have a website that you wish to be displayed, please indicate:

 

2011 Dues:
Regular membership:
65 euros:
  
Certified Psychotherapists & Counsellors:
100 euros:
  
Certified trainers:
135 euros:
 

2012 Dues:
Regular membership:
65 euros:
  
Certified Psychotherapists & Counsellors:
100 euros:
  
Certified trainers:
135 euros:
 
 

Payment can be made by:

 
Check or Money Order:

While we will accept checks designated payable in euros, we prefer to receive international money orders for euros payable to: the International Integrative Psychotherapy Association.
Please send the check or money order to
(in Dollars) to: Wayne Carpenter • 218 Peterson Street, Suite A. • Fort Collins, Co. 80524-2986
(in Euros) to: Thierry Clugery • 117, Bd de Strasbourg 76600 LE HAVRE – France
 
Credit card:
Visa:
MasterCard:
   
 
Name on credit card:
  
Account Number:
 
Expiration Date:
CVVS Code:
 (Visa/MasterCard: 3-4 digits at the end of numbers on upper right side of signature strip.)
 
IMPORTANT PLEASE READ BEFORE HITTING SUBMIT

If paying by CREDIT CARD, and all the info above is correct, please hit the SUBMIT button once
and wait for the thank you page. You have successfully paid.

If paying by CHECK, please hit SUBMIT and read instructions on the next page to complete your payment.

  

Please only hit SUBMIT once- it may take a minute to proces

For Financial questions contact Thierry Clugery at iipafinances@uniserve.com

For Membership questions contact Sandra Watson at iipamembership@uniserve.com